B.C. seniors at privately run care homes more likely to die in hospital: report

VICTORIA — B.C.’s seniors advocate has ignited a fiery debate over the types of elder care facilities in B.C., with a new report that says seniors who live in privately run care homes are far more likely to die in hospital than those who live in publicly run care homes.

The report, released Wednesday, said a senior in a facility run by a private company, a non-profit or a religious organization was 32 per cent more likely to be sent to their local emergency department and 54 per cent more likely to die while there.

The seniors advocate, Isobel Mackenzie, called the discrepancy “stunning” and wrote that private operators appear to be persistently failing compared to publicly run facilities when it comes to keeping seniors out of hospital emergency rooms, where their health is threatened by stress, a lack of mobility and hospital-acquired infections. Reducing the hospitalization rates could save B.C.’s health system $16 million a year, free up 15,481 beds and fund half a million additional care hours per year, she estimated.

The research intrigued B.C.’s health minister, led to calls of caution from academic experts and sparked an immediate backlash from the group that represents private care providers.

“Hospitals are not the best place for the frail elderly,” Mackenzie said in a statement. “We also know that most people want to die at home and for many of our frail and elderly seniors, ‘home’ is the residential care facility. With a rate more than double the public facilities, we really need to ask why contracted care facilities are seeing their residents die in the hospital.”

Almost 28,000 seniors in B.C. live in 293 publicly subsidized facilities. Roughly one-third of beds are operated by a public health authority. The rest are run by contractors (including both private companies, non-profits and religious organizations) who receive funding from the government.

Private care homes attacked the report, suggesting the research should be peer-reviewed for accuracy and accusing Mackenzie of instilling “fear and uncertainty” with questionable suppositions. Mackenzie said advisers from two B.C. universities helped her staff with analytical models that were independently verified as producing accurate figures.

“I caution the media and the public to really look hard at this report and make sure the source data and where it’s come from are accurate,” said Daniel Fontaine, CEO of the B.C. Care Providers Association, which represents most of the province’s private contractors.

Fontaine said the report did not substantiate whether the visits to the ER were inappropriate or not.

Health Minister Adrian Dix called the seniors advocate’s research a “good report” that has raised some important issues.

“The report is interesting, we’re looking at it and it’s a contribution,” he said Wednesday. “I think the numbers shown, that is pretty clear. But to draw too many conclusions, is not. I’m not, for example, saying the fact we’re understaffing private care homes is the cause of this. But it is a quality-of-care issue — that is beyond any doubt.”

Why private facilities have such higher hospitalization rates was not answered in Mackenzie’s research.

Mackenzie questioned whether factors could include the skill mix of private staff, a lack of stable clinical leadership, the generally lower pay rates, and the private sector’s practice of firing its employees and rehiring them at lower wages (a practice known as contract-flipping).

“Undoubtedly, some contracted care providers will be uncomfortable with some of these questions and fixing the problem may have a financial impact on the care home operators’ profitability,” wrote Mackenzie. “However, fixing the problem may also bring the care home operators more resources that will allow them to improve the outcome of care for their residents, and that is a goal that we should all embrace.”

The report’s inability to identify the cause of the higher hospitalization rates provided ammunition for critics.

“Rather than just issue yet another report with more questions and no answers and no conclusions and recommendations, I’d highly encourage the minister to recommend to the seniors advocate that she take a few moments to actually talk to the sector,” said Fontaine.

“It’s not helpful to have these types of reports with inflammatory headlines go out to the public.”

Jennifer Baumbusch, a University of B.C. seniors expert, said hospitalization rates could differ because public facilities have historically had better access to specialized resources and staff, and that not all private care homes can handle residents with complex health problems or help them plan for end-of-life care.

“It’s very difficult when you are working in a care facility and a resident and family are saying it’s time to go to the emergency room,” said Baumbusch, an associate professor in the school of nursing. “As a staff person, unless there’s been a lot of pre-planning, you can’t go against the wishes of the people. So that number 52 per cent says to me we also need to do a better job of preparing people and doing advanced planning across all types of sites.”

Baumbusch also urged caution with the lack of conclusions. “I think it needs to be a bit more of a thoughtful analysis to dig down and say why is this happening,” she said.

The private sector’s role in providing seniors care beds grew significantly over the past 16 years under the previous Liberal government. Whether the new NDP government will reverse that trend remains unclear. Dix said Wednesday that his plans for $240-million in additional funding over three years to improve direct care hours will go to a mixture of private, non-profit and public facilities.

Mackenzie wrote she was compelled to conduct her research after working alongside front-line staff in six B.C. hospitals and hearing from doctors and nurses that it was predictable to see some patients admitted because they came from care homes with high hospital referral rates.

“The data do support the first observation from emergency department clinicians that private care facilities are sending residents to the emergency department more frequently than public facilities, even though the data indicate they care for less complex and frail residents,” Mackenzie wrote in the report.

“The data also support the observation from some clinicians that, all things being equal, the contracted care facilities are not accepting the residents back to the facility as quickly as the public facilities, resulting in longer lengths of stay, higher conversion to alternative level of care (ALC) and higher rates of death in hospital.”

The most common ailments that result in a senior’s death in hospital are pneumonitis, pneumonia, sepsis, hip fractures, congestive heart failure and progressive lung diseases.

The B.C. Care Providers Association put out figures Wednesday that it said added context to Mackenzie’s report, arguing the number of potentially inappropriate hospital transfers from private facilities was actually much smaller than cited in the report, and could be as few as an average of five questionable transfers each year per facility. Mackenzie disputed that, saying some of the seniors who were appropriately accepted by hospitals as in-patients may still have been able to have their medical problem treated at their residential facility.

Dix said disagreements around the report and the issue of public versus private seniors care needs to be muted so that everyone can work together to improve the system.

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